CSB Investigation of Chevron Richmond Refinery
Pipe Rupture and Fire
Lauren Grim, Dan Tillema, Steve Cutchen, Mark Wingard, and Amanda Johnson
Chemical Safety Board, Western Regional Office of Investigations, 1 Denver Federal Center Way, Denver, CO 80225;
Lauren.grim@csb.gov (for correspondence)
Published online 14 September 2015 in Wiley Online Library (wileyonlinelibrary.com). DOI 10.1002/prs.11766
The U.S. Chemical Safety and Hazard Investigation Board
(CSB) investigated a pipe rupture of a high temperature light
gas oil line at the Chevron Richmond Refinery in Richmond,
CA. The CSB found technical, regulatory, and Chevron
organizational factors causal to the incident. This article is a
summary of the technical and organizational analysis pre-
sented in the CSB final investigation report on the Chevron
Richmond Refinery incident. V C 2015 American Institute of Chemi-
cal Engineers Process Saf Prog 34: 355–359, 2015
Keywords: incident investigation; process safety; sulfida-
tion corrosion; organizational analysis; pipe rupture; fire;
inherently safer design
INTRODUCTION
On August 6, 2012, the Chevron U.S.A. Inc. Refinery in Rich-
mond, California (“the Chevron Richmond Refinery”) experi-
enced a catastrophic pipe rupture in the #4 Crude Unit. The
incident occurred from piping referred to as the “4-sidecut”
stream, one of several process streams exiting the refinery’s
Crude Unit Atmospheric Column. The pipe rupture occurred
on a 52-inch long component of the 4-sidecut 8-inch line.
The ruptured pipe released flammable, high temperature
light gas oil, which then partially vaporized into a large, opa-
que vapor cloud that engulfed 19 Chevron U.S.A. Inc. (Chev-
ron) employees. Approximately 2 min following the release,
the released process fluid ignited. Eighteen of the employees
safely escaped from the vapor cloud just before ignition; one
employee, a Chevron refinery firefighter, was inside a fire
engine that was caught within the fireball when the process
fluid ignited. Because he was wearing full-body fire-fighting
protective equipment, he was able to make his way through
the flames to safety. Six Chevron employees suffered minor
injuries during the incident and subsequent emergency
response efforts.
This article is a summary of the technical and organiza-
tional analysis presented in the U.S. Chemical Safety and
Hazard Investigation Board (CSB) final investigation report
on the Chevron Richmond Refinery incident.
TECHNICAL FINDINGS
Metallurgical testing concluded that the rupture was due to
pipe wall thinning caused by sulfidation corrosion. Sulfidation
corrosion, also known as sulfidic corrosion, is a damage
mechanism that causes thinning in iron-containing materials,
C 2015 American Institute of Chemical Engineers
V variable sulfidation corrosion rates.
Process Safety Progress (Vol.34, No.4)
such as steel, due to the reaction between sulfur compounds
and iron at temperatures ranging from 4508F (2328C) to
1,0008F (5388C). Sulfidation corrosion is common in crude oil
distillation, where naturally occurring sulfur and sulfur com-
pounds found in crude oil feed, such as hydrogen sulfide, are
available to react with steel piping and equipment.
Sulfidation corrodes carbon steel at a much faster rate in
comparison with its effect on other materials of construction,
such as steels with a higher chromium content. Carbon steel
can also experience significant variation in corrosion rates
due to variances in silicon content, a component used in the
steel manufacturing process. Carbon steel piping containing
silicon content less than 0.10 wt % can corrode at accelerated
rates, up to 16 times faster than carbon steel piping contain-
ing higher percentages of silicon. Figure 1 shows how car-
bon steel corrosion rates can greatly vary depending on
silicon content.
Carbon steel piping is manufactured to meet certain spec-
ifications. Prior to the mid-1980s, multiple carbon steel speci-
fications were commonly and independently in use for
refinery piping, including American Society for Testing and
Materials (ASTM) A53B [1], ASTM A106 [2], and American
Petroleum Institute (API) 5L [3]. ASTM A53B and API 5L do
not contain minimum silicon content requirements for car-
bon steel piping, while ASTM A106 requires the piping to be
manufactured with a minimum silicon content of 0.10 wt %.
As a result, manufacturers have used different levels of sili-
con in the carbon steel pipe manufacturing process. In the
mid-1980s, pipe manufacturers began to comply simultane-
ously with all three manufacturing specifications (ASTM
A53B, ASTM A106, and API 5L) when manufacturing carbon
steel piping, which resulted in piping being manufactured
with at least 0.10 wt % silicon content due to the ASTM A106
requirement. As a result, the majority of carbon steel piping
purchased following this time period for refinery operations
likely has a minimum of 0.10 wt % silicon content. However,
piping purchased and installed prior to the mid-1980s could
still contain low silicon components susceptible to high, vari-
able sulfidation corrosion rates.
Over 95% of the 144 refineries in operation in the United
States, including the Chevron Richmond Refinery, were built
before 1985, before piping manufacturers began producing
carbon steel in compliance with all three manufacturing
specifications. Therefore, the original carbon steel piping
components in these refineries is likely to contain varying
percentages of silicon content and may experience highly
December 2015 355
Figure 1. Graph of sulfidation corrosion rates with respect
to silicon content in carbon steel. This graph shows how cor-
rosion rates increase in carbon steel containing decreasing
percentages of silicon. This information can be found in
Annex C of API RP 939-C. [Color figure can be viewed in the
online issue, which is available at wileyonlinelibrary.com.]
The Chevron Richmond Refinery 4-sidecut piping circuit
containing the 52-inch component that failed was constructed
of ASTM A53B carbon steel, which had no minimum specifi-
cation for silicon content. The 52-inch pipe component that
ruptured on the day of the incident had a silicon content of
only 0.01 wt %. Illustrating the inherent variability in ASTM
A53B carbon steel sulfidation corrosion rates, the elbow com-
ponent directly upstream of the 52-inch component that failed
had a silicon concentration of 0.16 wt % and showed consid-
erably less thinning (Figure 2).
Silicon Characterization Techniques
Determining silicon content in existing carbon steel pip-
ing and equipment in the field is a difficult undertaking. To
characterize the silicon content in each component of a pip-
ing circuit properly, every component must be inspected.
This is known as 100% component inspection. Two techni-
ques are used to identify low-silicon content and resulting
variable corrosion rates in existing carbon steel piping cir-
cuits with unknown chemical composition: (1) performing
chemical analysis; or (2) performing pipe wall thickness
measurements of every carbon steel component.*
Many field-portable instruments used for Positive Material
Identification (PMI) cannot adequately identify silicon con-
tent. If original manufacturing quality assurance data are not
available, as is generally the case with older plants, then
chemical verification requires destructive testing. Metal shav-
ings must be taken from each carbon steel piping compo-
nent for chemical analysis in a laboratory.
Carbon steel components containing low concentrations
of silicon can also be identified by performing one-time
thickness measurements of every component within a carbon
steel circuit. This practice is only useful as a means to ascer-
tain silicon content if the piping circuit has been exposed to
sulfidation corrosion for a long enough time period so that
variances in corrosion rate caused by differences in silicon
content may be detected. Both characterization techniques
*Pipe wall thickness measurement is difficult because of the high oper-
ating temperatures of piping subject to sulfidation corrosion. These
measurements are commonly made only when the piping is out of serv-
ice and cool, for example, during a unit maintenance activity.
356 December 2015 Published on behalf of the AIChE
Figure 2. A 4-sidecut piping sample showing the relative
thickness of low silicon piping on the left and the high sili-
con piping on the right. The ruptured 52-inch pipe compo-
nent (left) contained 0.01 wt % silicon, and the upstream
elbow component (right) contained 0.16 wt % silicon. The
initial nominal thickness of this piping was 0.322-inch. [Color
figure can be viewed in the online issue, which is available
at wileyonlinelibrary.com.]
require identification of each piping component, typically by
removing insulation (so every weld seam can be located).
Unlike silicon concentration, the chromium concentration
of steel can easily be verified in the field using portable PMI
instruments. As shown in the Modified McConomy Curves
from API RP 939-C (Figure 3), higher chromium steels are also
a better safeguard than carbon steel because sulfidation corro-
sion rates are greatly reduced. Carbon steel corrodes approxi-
mately 9 times faster than 9-Chrome steel, which contains 9%
chromium, and carbon steel corrodes approximately 120 times
faster than stainless steel, which contains 18% chromium.†
Inherently Safer Design
Efforts to improve chemical process safety require the
identification of process hazards, followed by the elimina-
tion, mitigation, or control of process hazards to reduce the
overall risk of a process. A hazard can be defined as a
“situation with the potential for harm.” Risk is then defined
as a function of both the consequence (hazard) and likeli-
hood (frequency) [4].
Risk reduction can be achieved using, in order of robust-
ness, inherently safer design, passive safeguards, active safe-
guards, and procedural safeguards [4]. This can be thought
†
These values were calculated using the McConomy Curves at 6308F.
DOI 10.1002/prs Process Safety Progress (Vol.34, No.4)

Figure 3. Modified McConomy Curves from API RP 939-C.
of as a tiered or hierarchical approach to risk management,
commonly referred to as a “hierarchy of controls.” The fur-
ther up the hierarchy, the more effective the risk reduction
achieved. Inherently safer design‡ reduces risk by perma-
nently reducing or eliminating a defined hazard itself, while
safeguards defined as passive (design features), active (detec-
tion and automatic response), and procedural (policies, pro-
cedures, training, inspection, use of personal protective
equipment) reduce risk by reducing the ultimate conse-
quence or likelihood of the hazard [4].
Thus, the use of a higher chromium steel alloy, such as 9-
Chrome, is an inherently safer design strategy that could
have prevented the Chevron Richmond Refinery pipe rup-
ture. Installation of 9-Chrome piping during turnaround
opportunities prior to the August 6, 2012, incident to replace
the 4-sidecut carbon steel would have both eliminated the
hazard of silicon-based variable corrosion rates within the
components of the 4-sidecut piping circuit and at the same
time also greatly reduced the underlying inherent rate of sul-
fidation corrosion. The use of 9-Chrome steel also simplifies
the procedural inspection safeguards required, as 100% com-
ponent inspection would not be required to monitor corro-
sion rates in steels containing at least 9% chromium; the
typical inspection strategy of monitoring corrosion rates
using a minimal amount of Condition Monitoring Locations
(CMLs) would be sufficient.
It is important to remember that inherently safer design
strategies are relative; a specific design can only be
described as inherently safer when compared with a differ-
ent design with regard to a specific hazard or risk [5]. A
design may be inherently safer by eliminating one hazard,
but can inadvertently introduce or aggravate another hazard
[6]. For this reason, performing a comprehensive, docu-
mented hazard analysis is vital for identifying the individual
hazards and the likelihood of those hazards occurring, fol-
lowed by identifying how they can be effectively controlled
to minimize overall risk. The review should include risks of
personal injury, environmental harm, and lost production,
as well as evaluating economic feasibility [7]. An inherently
safer systems review incorporated as an integral part of this
hazard analysis generates an optimized list of hazard con-
trol choices, offering various degrees of inherently safer
design strategies.
‡
The concept of “inherently safer design” was first established by Trevor
Kletz in 1977 in response to the 1974 Flixborough explosion in England.
He presented a lecture titled “What You Don’t Have, Can’t Leak” at the
Jubilee Lecture for the Society of Chemical Industry.
Process Safety Progress (Vol.34, No.4) Published on behalf of the AIChE
ORGANIZATIONAL FINDINGS
In the 10 years prior to the incident, a small number of
Chevron personnel with knowledge and understanding of
sulfidation corrosion made recommendations to increase
inspections or upgrade the material of construction in the 4-
sidecut piping. Their recommendations were not effectively
implemented. The process to implement important, safety-
critical projects within the Chevron Richmond Refinery was
not fully effective. As discussed below and depicted in Fig-
ure 4, a combination of (1) reliance on a turnaround man-
agement program that depended on only a fraction of
necessary data to make important process safety decisions,
(2) an unsuccessful bottom-up approach—with no manage-
ment oversight or accountability—for implementing a crucial
safety program, and (3) no formal method to track to com-
pletion the Chevron expert group’s findings and recommen-
dations ultimately caused these recommendations to not be
implemented.
Recommendations from Chevron Technical Expert
Group Not Implemented
Within Chevron is a separate business unit called the Chev-
ron Energy Technology Company (ETC). This unit provides
technology solutions and technical expertise for Chevron
operations worldwide. Chevron ETC technical staff has con-
siderable knowledge and expertise regarding sulfidation cor-
rosion, specifically with respect to corrosion rate variations
caused by differing silicon concentration in carbon steel pip-
ing. Chevron ETC employees have authored industry papers
on sulfidation corrosion and had significant influence in the
development of the industry sulfidation corrosion recom-
mended practice, API RP 939-C [8]. Metallurgists within ETC
had shared their knowledge on sulfidation corrosion via many
outlets over the years to employees at Chevron refineries,
including through a Sulfidation Failure Prevention Initiative
which was developed in 2009. The Sulfidation Failure Preven-
tion Initiative report was circulated to reliability managers and
metallurgists at the individual refineries, as well as to the cor-
porate reliability expert. The authors of the report chose to
send the report to these individuals specifically because they
seemed to be the right people to perform and advocate for
the necessary inspection and replacement work. However, the
CSB discovered that the Reliability Department at the Chevron
Richmond Refinery believed that the 100% component inspec-
tion initiative recommended by the ETC sulfidation failure pre-
vention guidance, while important safety work, was an
ambitious, unfunded, and unsupported initiative which could
not be effectively performed solely within the normal budget
and headcount resources of the Reliability group. Also, the
Reliability group made attempts to simply implement the ETC
alternative sulfidation mitigation strategy by recommending
replacement of the 8-inch 4-sidecut piping with higher chro-
mium steel. However, these recommendations were denied
on multiple occasions during the Chevron turnaround plan-
ning process. In practical terms, because Chevron ETC was a
separate business entity within the Chevron corporation and
had no direct authority over the reliability management within
the Chevron refineries, Chevron ETC sulfidation corrosion
experts had limited influence on what actually occurred
within refineries in their areas of expertise. At the time of the
incident, Chevron did not measure the implementation status
of ETC recommendations and new industry guidance deter-
mined by Chevron technical experts to be critical in ensuring
continued safe operations at Chevron refineries.
Turnaround Planning Group Denied Recommendations
The turnaround work approval process is guided by what
Chevron calls a “Framing Document.” A “Core Team” are the
DOI 10.1002/prs December 2015 357
Figure 4. Organizational decision-making schematic showing attempts to have carbon steel 4-sidecut piping 100% component
inspected or replaced with a higher chromium steel alloy. Attempts failed due to lack of accountability and lack of authority to
ensure recommendation implementation, and a rigid turnaround planning process that could not approve the 4-sidecut piping
replacement recommendations. [Color figure can be viewed in the online issue, which is available at wileyonlinelibrary.
com.]

main decision makers regarding what potential work items
meet the requirements of the Framing Document and, thus,
have the potential to be automatically included in the turn-
around. Recommendations were made for two turnarounds
prior to the incident to upgrade the 4-sidecut pipe to a
higher chromium material of construction. Inspection data
for the 4-sidecut piping, where measurements were histori-
cally taken on high-silicon fittings, indicated the 4-sidecut
piping could safely operate through 2016. Therefore, recom-
mendations to replace the 8-inch 4-sidecut piping during the
2007 and 2011 turnarounds were denied by the Core Team
in accordance with the Framing Document criteria.
Chevron’s data-driven turnaround management framework
led to unintended negative consequences. The current Chev-
ron Richmond Refinery turnaround planning framework
denies potential, discretionary turnaround work that does not
yet have hard data gathered from refinery equipment to sup-
port it, even if the work request is based on guidance issued
by the industry trade association, American Petroleum Insti-
tute. This rejection is true even if, as in the case of 100% com-
ponent inspection for sulfidation damage, the purpose of the
work request is to actually generate the hard data. The only
way a Chevron employee can have a work request approved
based solely on industry guidance is to appeal to management
for the work as an exception to the turnaround framing docu-
ment criteria. The CSB cannot conclusively state whether even
this method would have resulted in the approval to replace
the 4-sidecut line, but Chevron reliability and metallurgical
staff never attempted it. These individuals had not previously
been in the position of having to convince management of
the importance of their turnaround work recommendations,
so advocating the Sulfidation Failure Prevention Initiative and
persuading upper management to implement the ETC recom-
mendations would be a foreign work area for them. In addi-
tion, no high-level manager was assigned responsibility to
ensure that the ETC Sulfidation Failure Prevention Initiative or
other ETC sulfidation recommendations were included in the
turnaround scope. As a result, lower level employees who
did not have decision-making or funding authority were bur-
dened with convincing Chevron Richmond Refinery manage-
ment to implement new industry guidance and the ETC
recommendations.
Chevron Corporate Equipment Reliability Group
Unsuccessful
Chevron uses a corporate-wide equipment reliability
expert group, called the Fixed Equipment Reliability Business
Improvement Network (FER BIN), to monitor ongoing reli-
ability efforts at each Chevron refinery. It is intended to be a
“best practice” network that brings up to date changes in
industry standards into Chevron. It is headed by a technically
qualified subject-matter expert, the FER BIN Leader, who
advocates for the implementation of new industry best

358 December 2015 Published on behalf of the AIChE DOI 10.1002/prs Process Safety Progress (Vol.34, No.4)
practices or new reliability initiatives, such as the ETC Sulfi-
dation Failure Prevention Initiative.
The FER BIN 2012 business plan included a task item to
develop and implement “shaping plans” at Chevron refin-
eries to inspect for high temperature sulfidation. The FER
BIN Leader was charged with tracking progress of the shap-
ing plans at each refinery. However, the CSB found that the
FER BIN Leader had minimal authority to enforce implemen-
tation of the ETC Sulfidation Failure Prevention Initiative at
the Chevron Richmond Refinery.
In March 2012, 5 months prior to the incident, the FER
BIN Leader visited the Chevron Richmond refinery and iden-
tified that inspection of all carbon steel components suscepti-
ble to sulfidation corrosion was not being performed as
recommended by the ETC Sulfidation Failure Prevention Ini-
tiative. The FER BIN Leader identified that Richmond refinery
leadership needed to review and implement the 2009 Chev-
ron ETC Sulfidation Failure Prevention Initiative report and
recommendations.
When the FER BIN Leader visited refineries, he met solely
with inspection managers and inspectors to track progress.
He did not meet with higher management within the Rich-
mond refinery to give updates on whether the inspection
group was meeting corporate expectations. His assumption
was that the individual refinery lead inspectors would use
the knowledge he provided to shepherd new safety pro-
grams outlined in the refinery FER shaping plan. However,
that implementation strategy did not work at the Richmond
refinery.
No Leak Response Guidance
On the day of the incident, 2.5 h passed between leak
discovery and pipe rupture, during which personnel
attempted to identify the leak location, determine its cause,
and determine mitigation strategies. Chevron had no leak
response guidance or formal protocol for operations person-
nel, refinery management, emergency responders, or the
Incident Commander to refer to when determining how to
handle a process leak. Without a protocol, Chevron had no
formal system to ensure the right people were gathering all
important information before deciding on leak mitigation
strategies. Such an evaluation could have led to the conclu-
sion that the cause of the leak was general thinning due to
sulfidation corrosion, and clamping the pipe—a mitigation
strategy being considered—was not a viable solution
because the pipe likely did not have the structural integrity
to support a clamp. This realization likely would have
resulted in deciding to immediately shut down the unit. Fol-
lowing this incident, Chevron improved its internal policies
by developing and implementing a leak response protocol
for determining how to assess and mitigate leaks within the
refinery. The new leak response protocol would require unit
shutdown if a similar leak were to occur in a Chevron refin-
ery. The CSB made a recommendation to API to require
facilities to develop a process fluid leak response protocol.
Organizational Conclusions
The CSB found that Chevron management, engineers,
inspectors, and operators all see the importance of having
good process safety systems and the value of ensuring that
work processes are safe and equipment is reliable. Despite
this mindset and the existing programs, the Chevron Rich-
mond Refinery was unsuccessful in preventing the 4-sidecut
pipe from rupturing. A desire to be safe is not enough; to
ensure process safety, organizations must have a well-
Process Safety Progress (Vol.34, No.4) Published on behalf of the AIChE
designed integrated system, rigorous programs, and strong
leadership for these programs.
The critical flaw in Chevron’s safety programs is their reli-
ance largely on individual personnel assertions and initiatives
to implement new important safety programs—a bottom-up
approach. While this can occasionally be a successful
method, it is not a reliable way to implement safety-critical
programs.
Chevron can ensure the effectiveness of implementing
new safety-critical programs at the refinery level, such as the
ETC Sulfidation Failure Prevention Initiative, by developing a
formalized system that identifies one individual or group
with decision-making authority within each refinery to be
responsible and accountable for program implementation.
The implementation efforts can then be tracked as a leading
indicator in Chevron’s indicators tracking program.
ADDITIONAL INFORMATION
As a result of this investigation, the CSB made recommen-
dations to the American Petroleum Institute, the American
Society of Mechanical Engineers, Chevron, Contra Costa
County, the City of Richmond, the California State Legisla-
ture, the U.S. Environmental Protection Agency, and several
California agencies. The full report can be found at www.
csb.gov [9].
LITERATURE CITED
1. ASTM Standard A53/A53M-12, Standard Specification for
Pipe, Steel, Black and Hot-Dipped, Zinc-Coated, Welded
and Seamless, ASTM International, West Conshohocken,
PA, 2012.
2. ASTM Standard A106/A206M-11, Standard Specification
for Seamless Carbon Steel Pipe for High-Temperature
Service, ASTM International, West Conshohocken, PA,
2011.
3. API Specification 5L, Specification for Line Pipe, 45th ed.,
American Petroleum Institute, Washington, DC, 2012.
4. Center for Chemical Process Safety (CCPS), Inherently
Safer Chemical Processes – A Life Cycle Approach, 2nd
Edition, John Wiley & Sons, Inc.: Hoboken, NJ, Section
2.1, 2009.
5. Center for Chemical Process Safety (CCPS), Guidelines
for Engineering Design for Process Safety, 2nd Edition,
American Institute of Chemical Engineers: New York, NY,
Section 5.2, 2012.
6. Center for Chemical Process Safety (CCPS), Inherently
Safer Chemical Processes – A Life Cycle Approach, 2nd
Edition, John Wiley & Sons, Inc.: Hoboken, NJ, Section
3.6, 2009.
7. Center for Chemical Process Safety (CCPS), Inherently
Safer Chemical Processes – A Life Cycle Approach, 2nd
Edition, John Wiley & Sons, Inc.: Hoboken, NJ, Section
8.6.4.
8. API Recommended Practice 939-C, Guidelines for Avoid-
ing Sulfidation (Sulfidic) Corrosion Failures in Oil Refin-
eries, 1st ed., American Petroleum Institute, Washington,
DC 2009.
9. U.S. Chemical Safety Board, Final Investigation Report -
Chevron Richmond Refinery Pipe Rupture and Fire,
August 6, 2012, Report No. 2012-03-I-CA, 2015, Available
at: http://www.csb.gov/assets/1/19/Chevron_Final_Inves-
tigation_Report_2015-01-28.pdf. Accessed on August 20,
2015.
DOI 10.1002/prs December 2015 359